0301-354 (RER)H
N U)
W
� d
tr-' W
o Z
�0.
H �
J
~ aW.
U)
Z
V)
Ln
N
O�
aQ
U-
Z
,0QCCO
LL
XW —
ma3
OU
Z
co5
N a
I hereby affirm under penalty of perjury that I am licensed under provisions of
'Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
_3 HIC
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). f `./.
() I am exempt under Section B&P.C..for this reas6
Date -'��/ !` Signature of Owner...:: ,' - ss•- /
`77
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(.y) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUI14 ? Policy No. 04,601 UA 11'00101"1,4
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section,
00 of the Labor
Code, I!Stoll forthwith comply with those grovisions,,' i
Date:+/, .•t. Applicant
Warning: F2ilure to secure Workers' Compensation coverage is unlawfuland
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 4on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represen atives of this City to enter upon
the above-mentioned property for inspectlo p rposes.
Signature (Owner/Agent)"----1•• _ t� �" - / Date_ iT1,
r.
p BUILDING PERMIT PERMIT#
DATE VALUATION LOTw�i� •.� TRACT
JOB SITE
ADDRESS �.c1.yf.:}. R� i.ASr.'tb..., �iiY�?.4u �' �QGAPN
OWNER CONTRACTOR / DESIGNER / ENGINEER
1' "Ft":.'St €;c,`•r: "i f Y%"3I : 7);,? I.f
A,0'814
I'.%1, f tq'iX. t i)FiCi
USE OF PERMIT
?f..ltf"at�.I+11�3%i�; <z;.�i�^1, dA.'!?;tcw
1,5
C"•l�(il'>.II� ,I `s� :1'Fll? n ,f� 0N 9200
(7611 )6335.1010 CrIaL4 :4f 13123
811310.0:44 x;;D 3' 57 <g P .I; �. trC�%..trt•E:f i�I°
�S'.%F��� 14.If��A�y. fV14.afj(kI�".P.'�►4�i!�u
•tlAIX.A,,Vff}N
20,00 106 ?n}t
IINJf<.TIt":IM) COSI, or COIN1110"IT3:{JMY.01N
PEIRTAT'I'Flli'E S'VIWAI:>rS:# Y
Q' CaNe9'Y?t.UC IO N �' E, 101 -WO -418-000 % M Ai
SIT'RONK% MOTION YXI , R.S.S10 101-•00'1u=W..0&i ? I$' ,00
FEB 0 3 IUU*
CITY OF LA QUINTA
FINANCE DEPT.
x3'i3T3=•If)'I'.1;
I;EW, PRE' p
RECEIPT I DATE BY y,���` I DATE FI l�Ep�� I Ir�SP�C�70R
"'W0.00
VX)19.00
$0,010
�,"Jt•09AX)
Page of
DAVE STEAVENS
Inspection Services
PROJECT �(-A PROJECT #
ADDRESSS"V-SVI,a GG9.4Q �R 97
BLDG. PERMIT #
ENGINEER I t,, .,) SA J0 ,L .
INSPECTION TYPE
CLIENT -�e.N ;-,,3 e trr
DATE { 0 ?,' ) t... r�c.�Q A
ARCHITECTla r'.,4 fI ie- w-!
CONTRACTOR 1:- t,. )}%Jd r-ric. t c...
INSPECTION REPORT
IC- , t a, — l ?, / -S - `"1 — 2 L "-j e—.� } J �" til -.3 <.r ; w C -;k k � E e - i-_
..�:'rIN 1 G..-:� si-rr(....1a jdyi!t 1. r' Lt'
M•.J t Z I\ + 1 - L4 R 7 " � u.. (;,_ -5 b S r`1+' k_.i td)o7
r 1 L
/5 ;fid �► f rte r ��-rC t k + 1 t. �� k ' , r.r (Jr A-
A!
1 .r
(R A 410 AQ,-) OZ C-.r,J . ' c F 2
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantiallycomplies with approved plans, specifications and applicable sections of the building codes. This report covers
'the locations of the work inspected only and does not constitute engineering opinion or project control.
.ti
CERT. NO. �r'r �'; INSPECTOR NAME
_ (Print Clearly)
DATE INSPECTOR SIGNATURE c)
Page 1 of
DAVE STEAVENS
Inspection Services
ti S
PROJECT' se, A c l--. 7 --LIZC LOQ S PROJECT # r c? a t>
ADDRESS ` _ yrfy:, ' P693. '-r49-7 CLIENT (,,)CS7
!r.J' rw+calert 5 P u. A; "Itto DATE ( Ai-WIL. aaoo 3
BLDG. PERMIT #
ENGINEERu.wJ �;At oie- :I�Jt.
INSPECTION TYPE
ARCHITECT C-: L A A iZ C.1 -t
CONTRACTOR i�.(_ �'t'trliC" A C1 r i C
INSPECTION REPORT
t l:.) A
�1
lJ1►M ��,�-rte. °
1
Ll A
` - 7 -u PA 7 --,1 E j t
r
r
r
!J %." ( K l Lt..,, L✓ ` y � � /•'� i'' 6, Cr— A /6
J✓! G A i x! fa 1 LI i ( i. i' `f . # r `! \ t� 7%.
'7 a� t'� `f %" r `7 .� i! r-t'� T r� t , i A
f;1 ; tom'? 4 i ;,t l��f '.r� " i rte' r f �{.ra �J
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially�complies with approved plans, specifications and applicable sections of the building codes. This report covers
the locations of the`work inspected only -and does not constitute engineering opinion or project control.
CERT. NO. �r�' ark INSPECTOR NAME
(Print Clearly)
DATE // AN r!1.- �r ?C.� � INSPECTOR SIGNATURE+=/G� �_. � :=r_- .__ -• 3